Provider Demographics
NPI:1831281922
Name:JOHNSON, LATOYA CORDRELLIA (LMSW)
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:CORDRELLIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E WOODROW WILSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39217-0001
Mailing Address - Country:US
Mailing Address - Phone:601-940-8861
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39217-0001
Practice Address - Country:US
Practice Address - Phone:601-940-8861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC64851041C0700X
MSM6485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health